How South East Asia is rebooting medical tourism in a pandemic world

Slow recovery

The pandemic did huge damage to Malaysia’s previously thriving medical tourism sector, says Kuljit Singh, president at the Association of Private Hospitals of Malaysia, and ear, nose, and throat specialist at Kuala Lumpur’s Prince Court Medical Centre. “At many clinics and hospitals we went to zero [international patients] and the only medical tourism we saw was evacuation of patients for emergency care. In terms of tourists coming through the normal channels, it was almost zero.”

Individual specialists were also affected, some of whom say they relied on medical tourists for up to 25% of their total patient numbers before the pandemic. Overall, 2020 revenues more than halved after seven years of consecutive double digit growth. Two thirds (68%) of that business came from foreign patients living within the country, such as expatriates and holders of the Malaysia My Second Home visa.

The sector did see a limited number of patients, even during the worst of the crisis. In September 2020, the government introduced a medical travel “bubble” that allowed tourists to enter the country for treatment as long as they arrived by private aircraft and were not exposed to the wider community. According to MHTC, the “stringently monitored” bubble enabled the healthcare travel industry to make RM551m in 2021.

Since April the sector has started to recover, although it has been a slow start for those practising outside the capital, according to Boon Chong Tan, an orthopaedic surgeon in Penang. International flights to smaller states were not added to airline schedules until May, and medical tourists were reluctant to consider transiting on to a domestic route. But that’s now beginning to change, he says.

New world, new markets

In 2019, more than two thirds of Malaysia’s revenue from healthcare travel came from Indonesia and China, according to MHTC figures. China continues to face restrictions on outbound travel but remains a key focus for Malaysia in the longer term. One niche service Malaysia provides is fertility treatment, where it plans to target the approximately 90 million couples in China estimated to be looking to conceive a second child following abolition of the country’s one-child policy in 2015. Forty million of these couples are estimated to be over the age of 40.

In the shorter term Indonesia will remain the prime source of medical tourists, says Lee Kim Siea, a plastic surgeon based in Penang.

For travellers from Singapore, the US, Australia, and the UK, Malaysia is appealing because of its comparatively cheaper medical care compared with domestic healthcare. Before the pandemic, these four countries represented just 6.2% of all medical tourists arriving in Malaysia, but local experts say a greater focus on alternative treatments, or wellness, could increase that figure.

Already “a lot of new centres are emerging that now provide wellness services, or even standalone clinics that see wellness as their core business,” says Singh. The definition of wellness could be broad, he adds, encompassing everything from comprehensive health screening to minor cosmetic procedures, or even rehabilitative facilities designed to care for patients who have had more invasive procedures elsewhere. “To increase the portfolio of foreign tourists coming into the country, centres will certainly be looking at this option.”

It’s a strategy already being pursued by Thailand, which hosts the greatest number of medical tourists in the Association of Southeast Asian Nations, bringing in revenues of $1.8bn (£1.5bn)in 2019. The government has announced plans to grow its medical tourism sector by 5% in 2022, and has also focused on “wellness” facilities, from high end centres for covid-19 quarantine and recovery, to nutrition, herbology, traditional medicine, and anti-ageing treatments.

Singapore has set aside nearly SGD$500m (£300m) to support the recovery of tourism, and ministers forecast that SGD$1.1tn will come from “wellness tourism” by 2025 because of an increased interest in holistic healthcare post-pandemic.

More than just hospitals

To provide more holistic experiences means the onus isn’t just on hospitals or private clinics to adjust to a big influx of inbound medical tourists. “The challenge is the preparedness of the country to accept the number of medical tourists that could come to this country,” says Singh. “We’re still recovering from post-pandemic issues. We’re hoping that hotels are able to cope, but we need workers in the hotels and the hospitality sector to return to the levels they were prior to 2020. In hospitals we have the manpower, we did not let our staff go, but medical tourism requires a lot of other sectors to work together.”

For some individual doctors, meanwhile, the merits of medical tourism simply don’t outweigh the negatives. For Victor Cheong, a plastic surgeon in Kuala Lumpur, a brief stint working with specialist medical tourist agencies was enough. “I found there were too many negatives,” he says. These included not having a direct relationship with the patient prior to their arrival in Malaysia, pressure to carry out cosmetic procedures such as weight loss surgery that may be unnecessary, and the ethics of selecting a doctor based on price. “Most are coming here because it’s cheaper, and to me that’s a very bad way to start a doctor-patient relationship,” he says.

Cheong does treat international patients, including recent arrivals from Singapore, Indonesia, Hong Kong, and Ireland, but he relies on word-of-mouth recommendations and prefers to focus on local patients instead.

All of the local doctors that spoke to The BMJ described a change in the makeup of their practices post-pandemic, with a greater proportion of local patients and expatriates. The flipside of the global crash in medical tourism was a new stream of patients turning to their local providers, adds Kim Siea.

“There was a pool of patients that were intending to seek treatment overseas, but due to the restrictions on travel they sought treatment locally instead,” he says. “This additional income helped us to make up for the loss of foreign patients and hopefully, even now the borders have opened, they’ll continue to stay with us rather than going overseas.”